Acta Medica Croatica最新文献

Pressure ulcer is a localized injury of the skin and/or adjacent tissue, usually above bone protrusions. It is a result of pressureor pressure combined with shear stress, friction and humidity. With regard to long life and delayed healing, it is a chronicwound. Pressure ulcer appears as a consequence of a combination of micro-embolism, ischemia and myonecrosis. Thesepathophysiological processes provide an ideal medium for proliferation of microorganisms, predominantly bacteria, and developmentof infection. Progression in the development of pressure ulcer is a dynamic process manifesting in phases, eachof which is characterized by its own physiological-anatomical peculiarities and microbiological status. An open lesion withoutprotective barrier becomes contaminated immediately, and, shortly afterwards, colonized by physiological microflora of thehost and microbes from the environment. In the absence of preventive measures, the wound becomes critically colonizedand infected. The characteristic of chronic wound/pressure ulcer is that it is colonized, and the infection develops dependingon various factors in 5% to 80% of cases. The ability of microbes to cause infection depends on a number of factors,which include the pathogen and the host. The number and quantity of virulent factors, microbes, determines the virulencecoefficient, which is responsible for overcoming the host’s immune system and development of infection. In the developmentof pressure ulcer infection, two essential microbial factors predominate, i.e. the presence of adhesin and association withbiofilm. Thus, pressure ulcer infection as a chronic wound is characterized by a polymicrobial and heterogeneous populationof microbes, domination of biofilm phenotype as a primary factor of virulence present in 90% of cases, phenotype hypervariabilityof species, and resistance or tolerance of the etiological agents to all types of biocides. The most significant virulencefactor is biofilm. It is a corporative community of microbes with a clear architecture managed by quorum sensing molecules.It is through them that the communication between species takes place, the phenotype and virulence change, and resistancedevelops at the level of genome. The formation of biofilm takes place in several stages, and the speed is measured in hours.Microorganisms in the biofilm are protected from the action of the host’s immune system and, likewise, they are tolerant orresistant to antibiotics, antiseptics, and stress. Bacteria causing pressure ulcer infection are characterized as opportunistic,but also primarily pathogenic. The dominance and combination of species depend on the duration, localization and stageof pressure ulcer. The predominant etiological agents are Staphylococcus aureus, Streptococcus pyogenes, Pseudomonasaeruginosa and Peptostreptococcus spp. Nowadays, multiple-resistant strains predominate, such as MRSA, Acinetobacterspp. and Pseudomonas spp. A chronic wound such

It can be said that the occurrence and development of wounds, healing, delayed healing, and the notion of chronic woundare some of the basic characteristics of all living beings. When it comes to people, there are a number of processes that takeplace during wound healing, and even under ideal circumstances, they create a functionally less valuable skin tissue, alongwith structural and functional changes. Fibrosis in the form of hypertrophic scars and keloids, contractures and adhesionsare examples of excessive healing. Microcirculation is significantly different from healthy skin circulation with consequentialformation of local hypoxia and stagnation in lymph flow with edema. Poor functionality of the scar tissue, particularly in theareas exposed to stronger forces, can cause forming of wounds. Such wounds are hard to heal despite the inexistence ofother possible reasons for delayed healing, precisely because of their poor functionality and placement. The presence ofwound requiring long-term treatment affects all areas of patient life and leads to decline in the quality of life. Exemplified bycase presentation of a patient with post-traumatic wound in the scar area, in our office we showed a model of care basedon the principle of overall personalized care with the biopsychosocial approach. Diagnostic and therapeutic procedures includedwound assessment, biofilm and lymphedema detection, assessment of the patient’s psychosocial status, risk factorsfor wound healing, vascular ultrasound diagnostics, carboxytherapy as specialized adjuvant therapy, use of modern wounddressings, and compression therapy. Supportive psychotherapy was conducted in positive communication environmentduring treatment. In this way, in an atmosphere of cooperation with the patient, it was possible not only to influence theprocess of wound healing as the primary objective, but also to improve the quality of the patient’s life, as well as to influenceour professional satisfaction with the results achieved. Family doctors are involved in the care of chronic wound patientsas part of the multidisciplinary team of experts. Additional specific knowledge and skills are required for such care in orderto ensure overall quality care as a supplement of the existing knowledge, skills and working experience in family medicine.

This introduction has highlighted both the complex nature of the aetiology of pressure ulcer development and the complexnature of the assessment process intended to identify those patients who are or might be at an enhanced risk of pressureulcer development. The latter statement assumes that all patients cared for in any healthcare setting are vulnerable topressure ulcer development. Whilst it is acknowledged that the use of a risk assessment tool can be important in an overallpressure ulcer prevention strategy, it is important that the limitations of these tools are acknowledged and that they are notan finite assessment in themselves and that they should be used by a practitioner with a fundamental breadth of relevantknowledge and an appreciation of the range of appropriate preventative equipment/techniques available and the role of themulti-disciplinary team in the prevention of all avoidable pressure ulcers.

According to the European Pressure Ulcer Advisory Panel (EPUAP) definition, pressure ulcer is a local skin or subcutaneoustissue damage due to the force of pressure or friction or their combination. Pressure ulcers have accompanied humanssince the beginning and respective descriptions are found in the 19th century literature. Pressure ulcer is a major medical,social and health-economic problem because it is associated with a number of complications that require multidisciplinaryapproach in care and treatment. In affected patients, pressure ulcer causes quality of life reduction, discomforts, pain, emotionalproblems and social isolation. If the process of tissue decay is not halted, tissue damage will spread involving deep andwider structures, thus seriously compromising the patient general condition. Pressure ulcer usually develops at the sites ofprotrusions formed by lumbar spine, ischium, hip, ankle, knee or elbow, as well as in the areas with less developed adiposetissue. Any temporary or permanent immobility should be perceived as a milieu favoring the onset of pressure ulcer. Advancesin medicine and standards of living in general have prolonged life expectancy, thus also increasing the population at riskof chronic diseases including pressure ulcer. The aim of the study was to determine the relationship between the length ofbed-ridden condition and the occurrence of pressure ulcers in patients treated at Department of Cerebrovascular Diseasesand Intensive Neurology from January 1, 2012 until December 31, 2015. The study included patients with pressure ulcerverified on admission and those having developed pressure ulcer during hospital stay. Clinical picture of severe stroke predominatedin the majority of study patients. Patients were divided into groups according to health care requirements as classifiedby the Croatian Chamber of Nurses. Preliminary results indicated the length of bed-ridden condition to be associatedwith the occurrence of chronic wounds, and thus with increased cost and length of hospital treatment. Therefore, health caremethods and procedures should be focused on reduction of pressure ulcer development, quality health care, implementationof preventive measures, and continuous education of health care professionals.

Results of this clinical study on surgical treatment of pressure ulcers at Department of Plastic, Reconstructive and AestheticSurgery, Dubrava University Hospital showed that there was no difference between the 2011-2016 and 2003-2008 periods,indicating continuation of good surgical treatment planning and appropriate postoperative care. Despite the smaller numberof hospitalized patients in the 2011-2016 period (31 patients and 42 reconstructive procedures), the number of reconstructiveprocedure was similar to the recent 2003-2008 period (47 patients and 57 reconstructive procedures). The bestresults of reconstruction of sacral region pressure ulcer were achieved with fasciocutaneous and musculocutaneous flaps.Whenever possible, depending on the extent of the defect, musculocutaneous flaps should be preferred for reconstruction.It is especially suitable for pressure ulcer recurrence. For ischial region reconstruction, good results can be obtained by mobilizingthe semimembranosus and/or semitendinosus in defect gap. For trochanteric region, the tensor fascia lata flap is agood choice. For maximal functional and reconstructive results, a multidisciplinary approach in pressure ulcer treatment hasthe leading role in the modern concept of wound healing. Surgical treatment should always include radical debridement, ostectomyand well planned defect reconstruction. Conservative treatment should be support to surgical treatment with a focuson patient health care and high hygiene measures. In recent years (2011-2016), the usage of better conservative treatmentled to reduction of patient hospital stay and surgical treatment of pressure ulcer. Further ‘wound care’ nurses training inCroatia can lead the trend towards advanced practice nursing in pressure ulcer prevention and conservative treatment.

Damage to the central nervous system leads to the loss of motor control, loss of consciousness, sensory, cognitive andperceptive dysfunction. Patients are immobile in the early phase of recovery, therefore therapeutic approach demandsappropriate methods of patient positioning in bed. The positioning has to ensure conditions that will stimulate and promotefunctional rehabilitation and prevent complications of immobility. The positioning has to rely on functional assessment ofthe patient problem, while it should also be therapeutic and individually adjusted to the patient needs. In the methods ofpositioning an immobile patient, all medical team members take part, especially nurses, physical therapists and occupationaltherapists. Results of positioning are better if mobilization and integration of the abilities regained by the patient are included.

Malnutrition of elderly is an unrecognized condition, which can be effectively treated. It is associated with increased morbidity,hospitalizations, lower quality of life, increased mortality and significant costs. Body mass index (BMI) is not a sufficient measureof nutritional status of the elderly as it does not take into account changes in body structure and composition caused by aging.Various validated screening tools are recommended to use in elderly. General practitioner (GP) provides health care for all theelderly living in the community and therefore has an ideal opportunity to screen them for malnutrition. The objective of the articleis to show malnutrition screening tools for elderly, with an emphasis on those with sufficient sensitivity and specificity, applicablein family medicine. We searched databases Medline, Library of Congress and the Web of Science using selected keywords. Thesearch was limited to articles published in the last 20 years, with no language restrictions. We found 37 articles: in initial screeningwe excluded 20 and 17 articles remained. After retrieving all 17 full texts, one more was excluded so that the final numberof analyzed articles was 16. Among reviewed studies, following malnutrition screening tools were used for elderly: GeriatricNutritional Risk Index (GNRI), Malnutrition Screening Tool (MST), Mini Nutritional Assessment-Short Form (MNA-SF), NutritionalRisk Screening 2002 (NRS 2002), Malnutrition Universal Screening Tool (MUST), Short Nutritional Assessment Questionnaire 65+(SNAQ(65+)) and Australian Nutrition Screening Initiative (ANSI). The most frequently used tool (in nine articles) was MNA-SF, for itsconvenience, simplicity, sufficient sensitivity and specificity. Screening for malnutrition is the first step in nutritional care for the elderly.For the purpose of screening, GP has many tools available and should choose a simple one with sufficient sensitivity and specificity and easy toincorporate in the course of consultation with an elderly patient. It seems that such a tool for GP is MNA-SF.